Patient prosthesis mismatch


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  • Patient prosthesis mismatch

    1. 1. Factors Affecting Survival After Mitral Valve Replacement With Prosthesis–Patient Mismatch Presenter- Dr. JYOTINDRA SINGH in Patients
    3. 3. GOA for any given bioprosthetic valve is here defined as the area of the valve at its greatest opening. This is a valid approximation because the GOA of a bioprosthetic heart valve changes little during systole.
    4. 4. BACKGROUND Obviously, the best way to avoid PPM in the mitral position would be to repair rather than to replace the valve. Unfortunately, the options for preventing PPM in the mitral position are much more limited than in the aortic position. In particular, no alternative technique exists to implant a larger prosthesis, and the implantation of a homograft or of a stentless prosthesis is technically more demanding and associated with poor long-term durability. Hence, the preventive strategy can be oriented only toward the implantation of a prosthesis having a larger EOA for a given annulus size. 2
    5. 5. PATHOPHYSIOLOGY Hence, PPM in the mitral position can be equated to residual mitral stenosis with similar consequences (ie, the persistence of abnormally high mitral gradients and increased left atrial and pulmonary arterial pressures). The major consequence of pulmonary hypertension is right ventricular failure, which generally results from chronic pressure overload and associated volume overload with the development of tricuspid regurgitation. The persistence of high left atrial pressures may predispose to atrial fibrillation. This arrhythmia may compromise cardiac output and increase the incidence of thromboembolic complications. The passive elevation in pulmonary capillary pressure caused by elevated left atrial pressure also may lead to the development of pulmonary edema. Consistently, Masuda et al found that the maximum transprosthetic flow velocity is a strong determinantof the pulmonary capillary wedge pressure in children with mitral prostheses
    6. 6. OBJECTIVE Objective -The purpose of the current investigation was to identify patient subgroups in which PPM most influenced outcome after MVR, specifically examining the impact of patient age and prosthesis type on long-term survival. Place of study- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri Period of study- (May 1992 to June 2008)
    7. 7. Materials & Methods N=765 500 AGE PROFILE 460 450 400 350 >65yrs 305 370 300 250 AGE PROFILE N=765 200 150 < 65yrs 100 50 0 MEN WOMEN 395
    8. 8. Patient profile valve profile 500 440 450 400 350 325 300 250 200 150 100 50 0 valve profile
    9. 9. Materials & Methods 30 Indication % 26 40 30 20 10 0 37 25 27 23 20 18 15 11 11 7 10 % Concomitant surgery 8 5 1 0
    10. 10. Valve profile Valve size used % 100 90 30 30 24 80 62 20 60 bioprosthetic 50 mechanical 15 15 % 76 10 30 20 28 25 70 40 27 38 5 10 0 0 <65 yrs >65 yrs 23 to 27 mm 29mm 31 to 25mm 33 mm
    11. 11. PPM CRITERIA
    12. 12. Type of valve implanted appears normal
    13. 13. RESULTS- PPM EVALUATION Overall PPM 68 70 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 60 49% 50 45 37% 40 30 32 30 14% SEVERE 25 MECHANICAL 20 Bioprosthetic MODERATE ABSENT 10 0 2
    14. 14. Age based evaluation of PPM Prosthesis–patient mismatch was less common with mechanical valves than with biomechanical Moderate or severe PPM was more common in women and patients with endocarditis, diabetes, and chronic renal disease. Ejection fraction was similar among groups, as was the percentage of patients with an ejection fraction of 0.35 or less . With mechanical valves, the incidence of severe and moderate PPM was higher in younger patients , but with bioprosthetic valves, the incidence of PPM was higher in older patients
    15. 15. Independent predictors of Severe PPM 1) Advanced age 2) Diabetes Mellitus 3) Chronic renal disease 4) Bioprosthetic valves
    16. 16. Operative Mortality Overall mortality – 97/765 , 12.7 % Mortality varied with complexity of the procedure Independent predictors Active endocarditis, chronic renal insufficiency, peripheral vascular disease, non rheumatic origin, concomitant CABG, urgent or emergent status, implantation of a bioprosthetic valve Operative mortality was higher with severe PPM (24%) compared with moderatePPM (14% ) or absent PPM (8%)
    17. 17. CT FINDINGS appears normal
    18. 18. LATE SURVIVAL Of the 668 operative survivors, there were 265 late deaths; 403 patients were alive at late follow-up . Independent predictors of late death Advanced age, Earlier operative year, CRF Peripheral vascular disease, Congestive heart failure, Nonrheumatic origin, Concomitant CABG, Lower BSA, more significant PPM (lower EOA/BSA)
    19. 19. PPM- AGE STRATIFIED( Mechanical Valve) 100% 80% 82% 66% 77% 62% 60% 5 yrs 10 yrs 40% 20% 0% Without PPM With PPM 70% 60% 50% 40% 30% 20% 10% 0% 63% 40% 47% 30% Without PPM With PPM 5 yrs 10 yrs
    20. 20. PPM ( Age stratified) – Bioprosthetic VALVE 60% 50% 40% 30% 20% 10% 0% 58% 48% 51% 42% 5 yrs 10 yrs Without PPM With PPM 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 43% 30% 21% 5yrs 10 yrs 0% Without PPM With PPM
    21. 21. Comments “platelet and fibrin deposition, inflammation, granulation tissue, and finally encapsulation. Longterm device fibrous encapsulation with extension to adjacent tissues add to structural stability. ” Bioprosthetic valves undergo morphological changes of both the tissue material as well as the supporting structures, which may contribute to VP–PM. Fbrous sheath may also encapsulate the supporting structure of the valve, encroaching on the PHV orifice and also possibly causing valve leaflet or disk immobilization .
    22. 22. confirm that the lesion is solitary.
    23. 23. BIOPSY Vs RESECTION confirm that the lesion is solitary.
    24. 24. Impact of prosthesis-patient mismatch on tricuspid valve regurgitation and pulmonary hypertension following mitral valve replacement. Angeloni E, Melina G, Benedetto U, Roscitano A, Pibarot P, . Sapienza, University of Rome, Department of Cardiac Surgery, BACKGROUND: Mitral PPM can be equated to residual mitral stenosis, which may halt the expected postoperative improvement of PH and concomitant functional tricuspid regurgitation (fTR). Aim of the present study is to evaluate the impact of mitral prosthesis-patient mismatch (PPM) on late tricuspid valve regurgitation and pulmonary hypertension (PH). METHODS: A total of 210 patients undergoing isolated mitral valve replacement (MVR) were investigated. Mitral valve effective orifice area was determined by the continuity equation and indexed for body surface area (EOAi) and PPM was defined as EOAi≤1.2cm2/m2. Pulmonary hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)>40mmHg. Clinical and echocardiographic follow-up (median 27months) was 100% completed. A total of 88/210 (42%) patients developed mitral PPM. RESULTS: There were no significative differences in baseline and operative characteristics between patients with and without PPM. At follow-up, the prevalence of fTR≥2+ (57%vs.22%; p=0.0001), and PH (62%vs.24%;p<0.0001) were significantly higher in patients with PPM. On multivariable regression analysis, EOAi (p<0.0001) and preoperative left ventricular (LV) end-diastolic diameter (p<0.0001) were found to be independently associated with fTR decrease after MVR. In addition, EOAi (p<0.0001) and LV ejection fraction (p<0.0001) were independently associated with PH decrease after MVR. No significant differences in mortality rates were found between patients having or not PPM. CONCLUSIONS: This study shows that mitral PPM is associated with the persistence of fTR and PH following MVR. These findings support the realization of tricuspid valve annuloplasty when PPM is anticipated at the time of operation.
    25. 25. EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the actual valve size that wasimplanted. This should also be done at 6 to 12 months to evaluate the severity of VP–PM that will affect long-term outcomes. The grading of severity of VP–PM should be similar to another common LV outflow tract obstruction, namely,valvular AS. .To assess the effects of VP–PM on mortality, the goal should be to determine by multivariate analysis the role of VP–PM on mortality due to cardiac causes . The primary goal should be not to prevent VP–PM but rather to prevent severe VP– PM. Use of the EOAi as a continuous variable may help to define the level of severe VP–PM that results in increased mortality, and this may occur at a critical level of obstruction
    26. 26. 3 STEP PROTOCOL was elaborated by Pibarot and Dumesnil 1) calculate the BSA using the Dubois method; 2) determine the minimum EOA required to ensure an EOAi of 1.2 cm /m2 based on the minimum required EOAi for a given patient; 3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2. Although annular size is never a problem with ischemic regurgitation, for rheumatic patients with mitral stenosis, partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis. In contrast, patients with a heavily calcified, restricted mitral annulus may be at the mercy of valve selection, unless one wishes to embark on a complex annular decalcification procedure. Oversizing the valve can lead to disastrous complications, including disruption of the atrioventricular groove.